GS 110-91 · Violation

Name of Operation: REEDY CREEK ELEMENTARY ASEP Facility ID: 60001138 Consultant: RESHA WASHINGTON Operation Type: Center Case Number: Visit Date: 5/13/2025 Number Present: 38 Completed Date: 5/13/2025 Age: From 5 To 11 Total Minutes: 135 Time In: 02:45 PM Time Out: 05:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today's visit was to monitor applicable child care rules and laws during the facility’s Annual Compliance Visit. The facility has a Five-Star License issued March 18, 2018. The facility has an 18-month compliance history of 97% prior to today’s visit. The last Annual Compliance Visit was conducted May 20, 2024. The March 2023 Annual Compliance Monitoring Checklist for Child Care Centers and the Child Care Center Item Number Listing dated April 2025 were used to document compliance with child care rules. Upon arrival I utilized the buzzer located at the school’s front entrance to notify members of the office staff of my presence. A staff member greeted me via the intercom, and I introduced myself then explained the purpose of today’s visit. I was granted entry into the facility and then headed to the school’s office to check-in prior to heading to the cafeteria, where the After-School Enrichment Program is located. Upon entering, I was greeted by an unknown female. I inquired if Ms. A. Williams, Site Coordinator, was present and I was informed that she was not but Ms. R. Cruz, Program Assistant, was present, as well as Ms. A. Dobie. I, then, approached Ms. Cruz and informed her of the purpose of today’s visit. Ms. Cruz informed that Ms. Williams was currently not onsite but Ms. Dobie was the current Site Coordinator Trainee, so she could further assist me. I then approached Ms. Dobie to introduce myself and explain the purpose of today’s visit. Ms. Dobie shared that she had currently been in her role for just a few weeks, so I provided additional information about the expectations and process for today’s visit. Shortly thereafter, I began a walk-through of the program. Children were observed engaging in afternoon snack, personal care routines, table toys, independent play and group activities. There were thirty-eight (38) children present between the ages of five (5) and eleven (11) years of age. They were split into three (3) groups with three teachers present today. After-school staff were observed greeting parents during departure and engaging with children in a nurturing manner. During the walk-through of the program bulletin boards were monitored. Individual group lesson plans were observed posted for all three groups present, but the lesson plans present for Groups One and Two were observed dated May 5th-May 9th. This information was shared with staff and they were reminded that all post activity plans need to be both current and age-appropriate. Daily attendance records and sign-out sheets were monitored for all three groups. Each was observed to be completed as required. Program records were monitored. Monthly fire drills were reviewed for the past twelve months. It was observed they did not occur in December 2024 and January 2025, as required, but they did occur in the months following. Quarterly emergency drills were monitored and it was observed that the last one occurred in November 2024. Ms. Dobie was informed that one should have occurred in February 2025 and the next one is due in May 2025, as they are required to take place every three months. She stated that she understood. Playground inspection checklists were not available for review. Emergency medication was monitored. It was observed that one child with a chronic medical condition requiring life-saving medication had medication present but there was no completed permission to administer medication form on file. The program’s Emergency Preparedness and Response plan was monitored and observed to not have been updated annually, as required, or containing current information for all staff. The program’s incident log was monitored. It was observed that although two incidents had occurred requiring incident reports to be completed there was no corresponding incident log available for review. Hazardous materials were observed stored, as required. Children’s files were reviewed, and each was found to be compliant. The program's allergy list was reviewed during today’s visit and it was observed that six (6) of the children listed were no longer enrolled in the program. This was discussed with Ms. Dobie and corrected during the visit. Four (4) staff files were monitored. Each was observed to be compliant. The last sanitation inspection was conducted on March 31, 2025 with 4 demerits and a superior rating. The last fire inspection was conducted on August 20, 2024. There were eight (8) violations cited today. Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. During the walk-through of the program bulletin boards were monitored. Individual group lesson plans were observed posted for all three groups present, but the lesson plans present for Groups One and Two were observed dated May 5th-May 9th. GS 110-91(12); .0508(a) 508 Special diet or food allergy information was not posted where they can be seen in food preparation and eating areas. The program’s allergy list was reviewed during today’s visit and it was observed that six (6) of the children listed were no longer enrolled in the program. .0901(g) 805 Fire drills were not practiced monthly and/or the drill record was incomplete. Monthly fire drills were reviewed for the past twelve months. It was observed they did not occur in December 2024 and January 2025, as required, but they did occur in the months following. .0604(t); .0302(d)(5) 853 Incident logs were not completed and maintained as required. The program’s incident log was monitored. It was observed that although two incidents had occurred requiring incident reports to be completed there was no corresponding incident log available for review. .0802(g)(1-6) 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. Playground inspection checklists were not available for review during today's visit. .0605(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. Quarterly emergency drills were monitored and it was observed that the last one occurred in November 2024. .0604(u);.0302(d)(8) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The program’s Emergency Preparedness and Response plan was monitored and observed to not have been updated annually, as required, or containing current information for all staff. .0607(e) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. Emergency medication was monitored. It was observed that one child with a chronic medical condition requiring life-saving medication had medication present but there was no completed permission to administer medication form on file. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Corrective Action: Any outstanding violations must be corrected immediately. The childcare provider is expected to maintain all applicable childcare requirements at all times. The provider will send me a compliance letter explaining how she corrected today’s violation and the steps she put in place to ensure on going compliance on or before Tuesday May 27, 2025 to the email listed below. Failure to correct the violation and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Technical Assistance: -During today’s visit the Site Coordinator Trainee and I discussed the expectation that all applicable childcare requirements are always maintained. We spoke specifically about the areas where violations were cited during today’s visit including but not limited to completion of lesson plans, emergency drills, medication, incident logs, completion of outdoor playground expectations, general safety requirements and general childcare requirements. -Ms. Dobie and I discussed the importance of having a system in place to ensure all program documentation, inspections and other regulatory expectations are both maintained and completed, as required, in the event of an extended absence of the assigned Site Coordinator. I recommend following up with the CMS site liaison to request additional support and information on site specific processes. -The Site Coordinator Trainee and I discussed the importance of having an up-to-date Allergy list posted and accessible at all times to ensure the needs of all children are being met to maintain a safe environment. We discussed reviewing consistently to make necessary changes, as they occur. - Please check your email regularly for updates from the Division of Child Development and Early Education (DCDEE) and from your assigned childcare consultant. Thank you for your time and if you have any questions, please contact Resha K. Washington at 704-910-7947 or email resha.washington@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

10A NCAC 09 .2818 · Violation

Name of Operation: REEDY CREEK ELEMENTARY ASEP Facility ID: 60001138 Consultant: RESHA WASHINGTON Operation Type: Center Case Number: Visit Date: 5/20/2024 Number Present: 45 Completed Date: 5/20/2024 Age: From 5 To 11 Total Minutes: 180 Time In: 02:45 PM Time Out: 05:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today's visit was to monitor applicable child care rules and laws during the facility’s Annual Compliance Visit. The facility has a Five-Star License issued March 18, 2018. The facility has an 18-month compliance history of 97% prior to today’s visit. The last Annual Compliance Visit was conducted May 22, 2023. The March 2023 Annual Compliance Monitoring Checklist for Child Care Centers and the Child Care Center Item Number Listing dated March 2024 were used to document compliance with child care rules. Upon arrival I rang the bell at the school’s front entrance where I introduced myself and explained the purpose of today’s visit. I was granted entrance into the facility and then headed to the school’s cafeteria where the After-School Enrichment Program is located. Upon entry I was greeted by Ms. A. Williams, Site Coordinator, and Ms R. Cruz, Program Assistant. I introduced myself and explained the purpose of today’s visit. Children were observed engaging in afternoon snack, personal care routines, table toys, independent play, group activities and student led activities. There were forty-five (45) children present between the ages of five (5) and eleven (11) years of age. They were split into two (2) groups, as there were currently only two teachers present today. Ms. Williams informed me that the children are typically in three groups but the program’s substitute called out today, so they had to combine. Ms. Williams and I discussed that the ratio for any group in her program with five year old school-aged children present is one teacher to fourteen children and the maximum group size for each group is twenty-five children, so her program is currently out of ratio. She stated that she understood this. After-school staff were observed greeting parents during departure and engaging with children in a nurturing manner. A walk-through of the program was conducted. Bulletin boards were monitored, and found to contain all required information current and posted as required. The program’s current license and the NC childcare law summary were also prominently posted. Daily attendance records and sign-out sheets were monitored, both were being completed as required. Program records were monitored. Emergency drills were monitored and found to be documented and being conducted as required. Emergency medication was monitored and it found to be in compliance. Two (2) permanent staff files were monitored. They were each found to be in compliance. The last sanitation inspection was conducted on September 21, 2023 with 2 demerits and a superior rating. The last fire inspection was conducted on November 23, 2023. Groups were observed to be adequately supervised during today’s visit. There was one (1) violation cited today. Violation Number Comment Rule 1756 Enhanced staff/child ratios and group sizes were not met. There were forty-five (45) children present between the ages of five (5) and eleven (11) years of age. They were split into two (2) groups, as there were currently only two teachers present today. 10A NCAC 09 .2818 Corrective Action: Any outstanding violations must be corrected immediately. The childcare provider is expected to maintain all applicable childcare requirements at all times. The provider will send me a compliance letter explaining how she corrected today’s violation and the steps she put in place to ensure on going compliance on or before Monday June 03, 2024 to the email listed below. Failure to correct the violation and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Technical Assistance: - Please check your email regularly for updates from the Division of Child Development and Early Education (DCDEE) and from your assigned childcare consultant. -It was discussed that it is necessary to have a plan in place to ensure adequate coverage and ratio is always maintained in the event a staff member is absent. I recommended following up with the CMS site liaison to request additional support and information on available substitutes. Thank you for your time and if you have any questions, please contact Resha K. Washington at 704-910-7947 or email resha.washington@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .0802 · Violation

Name of Operation: REEDY CREEK ELEMENTARY ASEP Facility ID: 60001138 Consultant: RESHA WASHINGTON Operation Type: Center Case Number: Visit Date: 12/12/2023 Number Present: 37 Completed Date: 12/12/2023 Age: From 6 To 11 Total Minutes: 180 Time In: 03:00 PM Time Out: 06:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today's visit was to monitor applicable child care rules and laws during a routine unannounced visit. The facility has a Five-Star License issued March 18, 2018. The facility has an 18-month compliance history of 100% prior to today’s visit. The last Annual Compliance Visit was conducted May 22, 2023. The following was monitored using the August 2023 Master Childcare Center Item Number Listing: supervision, capacity, staff/child ratios, adequate and approved space, criminal background checks, CPR, First Aid, special training, new staff records, storage of hazardous products, and storage of medication. Upon arrival I checked in at the school’s front office where I introduced myself and explained the purpose of today’s visit. I was shown to the school’s cafeteria where the After-School Enrichment Program is located. Upon entry I was greeted by Ms. A. Williams, Site Coordinator in training, and Ms R. Cruz, Program Assistant. I introduced myself and explained the purpose of today’s visit. Children were observed engaging in personal care routines, table toys, independent play, group activities and student led activities. There were thirty-seven (37) children present between the ages of six (6) and eleven (11) years of age. They were split into two (2) groups, as there are currently only two permanent teachers on staff. Ms. Williams informed me that the program’s third teacher recently retired and a program substitute would be arriving shortly. The third teacher was observed arriving slightly after 4pm, the groups were then separated into three (3) smaller groups. After-school staff were observed greeting parents during departure and engaging with children in a nurturing manner. Groups were within staff/child ratio and adequately supervised. Bulletin boards were monitored, and it was observed that the Emergency Medical Care Plan was not complete and up to date. The posted EMCP listed a staff member that was no longer employed with the program and all required information was not included. The license and NC childcare law summary were prominently posted. Daily attendance records and sign-out sheets were monitored, both were being completed as required. Program records were monitored. Emergency drills were monitored and found to be documented and being conducted as required. Ms. Williams stated that there are currently no children enrolled in the program with documented allergies or chronic medical conditions that require emergency medication to be accessible onsite. I monitored three (3) staff files for current Criminal Background Checks, current First Aid certification and current CPR certifications. They were each found to be in compliance. - The last sanitation inspection was conducted on September 21, 2023 with 2 demerits and a superior rating. - There was no recent fire inspection conducted by Charlotte Fire Department available for review. There were two (2) violations cited during today’s visit. Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. There was no recent fire inspection conducted by Charlotte Fire Department available for review. 10A NCAC 09 .0304(a) 832 There was no written emergency medical care (EMC) plan. Bulletin boards were monitored, and it was observed that the Emergency Medical Care Plan was not complete and up to date. The posted EMCP listed a staff member that was no longer employed with the program and all required information was not included. 10A NCAC 09 .0802(a) Corrective Action: Any outstanding violations must be corrected immediately. The childcare provider is expected to maintain all applicable childcare requirements at all times. The provider will send me a compliance letter explaining how she corrected today’s violation and the steps she put in place to ensure on going compliance on or before Tuesday December 26, 2023 to the email listed below. Failure to correct the violation and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Technical Assistance: - Please check your email regularly for updates from the Division of Child Development and Early Education (DCDEE) and from your assigned childcare consultant. -It was discussed to ensure all documentation is completed in its entirety and all posted information is up to date and current. -It was discussed to follow-up with the CMS site liaison to obtain copies of any pertinent, updated or missing staff or program paperwork to have onsite for easy access. Thank you for your time and if you have any questions, please contact Resha K. Washington at 704-910-7947 or email resha.washington@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .0304 · Violation

Name of Operation: REEDY CREEK ELEMENTARY ASEP Facility ID: 60001138 Consultant: RESHA WASHINGTON Operation Type: Center Case Number: Visit Date: 12/12/2023 Number Present: 37 Completed Date: 12/12/2023 Age: From 6 To 11 Total Minutes: 180 Time In: 03:00 PM Time Out: 06:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today's visit was to monitor applicable child care rules and laws during a routine unannounced visit. The facility has a Five-Star License issued March 18, 2018. The facility has an 18-month compliance history of 100% prior to today’s visit. The last Annual Compliance Visit was conducted May 22, 2023. The following was monitored using the August 2023 Master Childcare Center Item Number Listing: supervision, capacity, staff/child ratios, adequate and approved space, criminal background checks, CPR, First Aid, special training, new staff records, storage of hazardous products, and storage of medication. Upon arrival I checked in at the school’s front office where I introduced myself and explained the purpose of today’s visit. I was shown to the school’s cafeteria where the After-School Enrichment Program is located. Upon entry I was greeted by Ms. A. Williams, Site Coordinator in training, and Ms R. Cruz, Program Assistant. I introduced myself and explained the purpose of today’s visit. Children were observed engaging in personal care routines, table toys, independent play, group activities and student led activities. There were thirty-seven (37) children present between the ages of six (6) and eleven (11) years of age. They were split into two (2) groups, as there are currently only two permanent teachers on staff. Ms. Williams informed me that the program’s third teacher recently retired and a program substitute would be arriving shortly. The third teacher was observed arriving slightly after 4pm, the groups were then separated into three (3) smaller groups. After-school staff were observed greeting parents during departure and engaging with children in a nurturing manner. Groups were within staff/child ratio and adequately supervised. Bulletin boards were monitored, and it was observed that the Emergency Medical Care Plan was not complete and up to date. The posted EMCP listed a staff member that was no longer employed with the program and all required information was not included. The license and NC childcare law summary were prominently posted. Daily attendance records and sign-out sheets were monitored, both were being completed as required. Program records were monitored. Emergency drills were monitored and found to be documented and being conducted as required. Ms. Williams stated that there are currently no children enrolled in the program with documented allergies or chronic medical conditions that require emergency medication to be accessible onsite. I monitored three (3) staff files for current Criminal Background Checks, current First Aid certification and current CPR certifications. They were each found to be in compliance. - The last sanitation inspection was conducted on September 21, 2023 with 2 demerits and a superior rating. - There was no recent fire inspection conducted by Charlotte Fire Department available for review. There were two (2) violations cited during today’s visit. Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. There was no recent fire inspection conducted by Charlotte Fire Department available for review. 10A NCAC 09 .0304(a) 832 There was no written emergency medical care (EMC) plan. Bulletin boards were monitored, and it was observed that the Emergency Medical Care Plan was not complete and up to date. The posted EMCP listed a staff member that was no longer employed with the program and all required information was not included. 10A NCAC 09 .0802(a) Corrective Action: Any outstanding violations must be corrected immediately. The childcare provider is expected to maintain all applicable childcare requirements at all times. The provider will send me a compliance letter explaining how she corrected today’s violation and the steps she put in place to ensure on going compliance on or before Tuesday December 26, 2023 to the email listed below. Failure to correct the violation and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Technical Assistance: - Please check your email regularly for updates from the Division of Child Development and Early Education (DCDEE) and from your assigned childcare consultant. -It was discussed to ensure all documentation is completed in its entirety and all posted information is up to date and current. -It was discussed to follow-up with the CMS site liaison to obtain copies of any pertinent, updated or missing staff or program paperwork to have onsite for easy access. Thank you for your time and if you have any questions, please contact Resha K. Washington at 704-910-7947 or email resha.washington@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times